The Controversial Role of Prophylactic Gastrostomy Feeding Tubes in Head and Neck Cancer Patients undergoing Chemoradiot

1. The Controversial Role of Prophylactic Gastrostomy Feeding Tubes in Head and Neck Cancer Patients undergoing Chemoradiotherapy (CRT) Leigh Manske

2. Controversial Topic I researched and compared the risks and benefits of placing head and neck cancer patients on feeding tubes during adjuvant chemoradiotherapy treatments. Many facilities place head and neck patients on feeding tubes prophylactically. This paper challenges the effectiveness of this practice when considering probable long term side effects that accompany this procedure.

3. Contradicting Data In a study following head and neck patient’s over the span of 2 years, only 26 of the 35 patients prophylactically placed on gastrostomy tubes actually utilized their tube for feeding and fluids throughout the duration of their treatment.   In another study, 32% of the patients who were not initially placed on a feeding tube at the beginning of treatment later required gastrostomy tube placement within the first month

4. Positive Outcomes Associated with PEG Tube Placement Reduced Weight Loss 19 lb average wt. loss in PEG H&N patients 1 43 lb average wt. loss in non-PEG H&N patients1(blue) Reduced Nutritional Deterioration 20% occurrence up to 3 mo. in PEG H&N patients2 96% occurrence up to 3 mo. in non-PEG H&N patients2 (green) Reduced need for Intravenous Hydration Required in 17% of PEG H&N patients1 Required in 54% of PEG H&N patients1

5. Negative Outcomes Associated with PEG Tube Placement Late Toxicities Acute Toxicities Quality of Life Dependency Infection Complications

6. Acute Toxicities induced by H&N Chemoradiotherapy Mucositis Odynophagia Dysphagia Xerostomia Dysguesia Nausea Vomiting

7. Late Toxicities induced by H&N Chemoradiotherapy High Grade Dysphagia 46% PEG H&N patients 27% of non-PEG H&N patients Esophageal Stricture 30% PEG H&N patients Prophylactic PEG placement has significantly higher rates of esophageal toxicity Speech Outcomes Swallowing Outcomes

8. Quality of Life and Dependency Short Term Side effects magnified with concurrent chemo QOL scores proportional to nutritional intake immediately following treatment Long Term Deterioration still significantly associated with poor dietary intake At 6 months 41% of PEG H&N patients still feeding tube dependent 8% of non-PEG H&N patients still feeding tube dependent At 12 months 21% of PEG H&N patients still feeding tube dependent 0% of non-PEG H&N patients still feeding tube dependent Long term dependence decreases among patients who are reactively placed on feeding tubes vs. prophylactic. ¼ of advanced head and neck patients will die while still GT dependent

9. Complications Enteral feeding complication rates tend to be higher in head and neck patients Procedural complication rates are about 5-10% with feeding tubes lose the catheter within the peritoneal cavity implantation seeding of the tumor into the stomach if using nasogastric feeding tube Minor upkeep complications occur in as many as 50% of gastrostomy dependent patients cellulitis, abscess, fasciitis, colon perforation and tumor implantation port infection and minor leakage leading to morbidity in 15% Major complications requiring surgical revision arise in about 7%

10. Predictive Factors for High Risk Gastric Tube Placement It is estimated that 1 in 7 head and neck patients will require a feeding tube at some point throughout their treatment and nearly 20% will be placed during or after receiving CRT. This is more likely with: CRT to the base of tongue, oral cavity, nasal cavity, salivary glands, nasopharynx and oropharynx Bilateral RT to the oropharynx or nasopharynx who present with existing dysphagia Advanced stage and/or unresectable head and neck tumors Early stage laryngeal cancer Pre-treatment weight loss

11. Prognosis Positive 2-year survival rate in head and neck patients with enteral feeding or supplementation Weight loss is associated with greater morbidity and poor tolerability of treatment Patients presenting with a nutritional deficit prior to tx. have only a 7.5% OS compared to 57.7% OS without malnutrition. There remains no significant difference in 3-year survival with or without prophylactic GT during tx.

12. Alternative Nutritional Intervention Change of treatment modality (IMRT is more tolerable than conventional) Medication alteration Oral antifungal solutions Anesthetics Anti-inflammatory drugs Antiemetics Dietary modification as a first-line approach with loss of appetite Easy to follow diet that the patient can realistically follow 90% of patients receiving only oral nutritional guidance improved anorexia, nausea, vomiting, xerostomia and dysgeusia within 3 months

13. In Conclusion As neither preventive nor reactive gastric feeding tube placement show statistical significance in terms of treatment delay and overall survival, it is to be concluded that prophylactic gastrostomy tube placement is not beneficial for patients unless they are initially deemed high risk.  

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